These treatments should not be used if you are pregnant or breastfeeding.

Yes

No

Have you been diagnosed with acne by your GP? *

Yes

No

Are you allergic to Lymecycline (tetracycline)? *

Yes

No

Have you been diagnosed with liver or kidney disease? *

Yes

No

Are you aware you shouldn't be taking Lymecycline antibiotic tablets whilst using Zineryt or Duac (topical antibiotics)? *

Lymecycline can be taken whilst using Differin and Epiduo

Yes

No

Are you aware it usually takes 8 weeks or more of continuous usage for treatments to work? *

If there's no improvement after 4 months, treatment should be stopped or changed.

Yes

No

Are you aware, if acne has cleared up, treatment can sometimes be stopped or reduced after 4 to 6 months? *

Yes

No

Are you aware you should see your GP if acne is scarring or getting worse? *

Yes

No

Do you suffer with any other skin conditions *

Yes

No

Please provide further details

Do you agree to consult your GP in the following circumstances: *

Your symptoms change or get worse

Your acne causes scarring

Your acne causes you to feel depressed

You experience any side effects from your treatment

Yes

No

Do you agree to the following? *

You will read the patient information leaflet supplied with your medication

You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.

The treatment is solely for your own use

You have answered all the above questions accurately and truthfully. You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.